From the Guidelines
A modified barium swallow study (MBSS) or videofluoroscopic swallow study (VFSS) is the primary diagnostic tool for evaluating G-tube reflux with aspiration risk. This procedure involves giving the patient barium or another contrast material through the G-tube while taking real-time X-ray images to visualize the movement of the contrast material. The study can directly observe if contents from the stomach are refluxing up the esophagus and potentially entering the airway (aspiration). For a comprehensive evaluation, a nuclear medicine gastric emptying study may also be performed to assess how quickly the stomach empties, as delayed emptying can increase reflux risk. Additionally, pH monitoring or impedance testing can help quantify the frequency and severity of reflux episodes.
These diagnostic studies are essential because G-tube reflux with aspiration can lead to serious complications including aspiration pneumonia, chronic lung disease, and respiratory distress. The results guide management strategies such as adjusting feeding schedules, changing formula concentration, modifying G-tube placement, or considering medications like proton pump inhibitors or prokinetics to reduce reflux risk. According to the guidelines for the early management of patients with acute ischemic stroke 1, sustaining nutrition is important, and impairments of swallowing are associated with a high risk of pneumonia, which can be a consequence of aspiration.
Key points to consider when evaluating G-tube reflux with aspiration risk include:
- The use of a formal dysphagia screening protocol can improve compliance with dysphagia screenings and reduce the risk of pneumonia 1
- A water swallow test performed at the bedside is a useful screening tool, and a wet voice after swallowing is a predictor of a high risk for aspiration 1
- Clinical signs may not identify patients at risk for aspiration, and further testing, including a video fluoroscopic evaluation of swallow or a fiber optic endoscopic evaluation of swallow, may be performed if indicated 1
From the Research
Diagnosis of G-Tube Reflux with Aspiration Risk
To diagnose gastrostomy tube (G-tube) reflux with aspiration risk, several studies suggest the use of scintigraphy as a useful tool.
- Scintigraphy can detect gastroesophageal reflux and determine whether percutaneous gastrostomy (PG) tubes cause reflux 2.
- A modified scintigraphic technique can be used to detect gastroesophageal reflux (GER) and lung aspiration in patients fed by percutaneous endoscopic gastrostomy (PEG) 3.
- Scintigraphy is useful in assessing GER in PEG-fed patients, especially in those with neurological dysphagia 3.
Studies on G-Tube Reflux
Several studies have investigated G-tube reflux using scintigraphy:
- A study published in 1993 found that scintigraphy was useful in selecting patients who can be safely maintained with a PG tube without an increase in morbidity or mortality associated with reflux and aspiration 2.
- A study published in 1998 found that scintigraphy can detect GER and lung aspiration in patients fed by PEG, and that GER is a major problem in patients with PEG, especially in those with neurological dysphagia 3.
- A study published in 2020 developed and validated a scintigraphic test that evaluates reflux at both sites in patients at high risk of laryngopharyngeal reflux and lung aspiration 4.
- Other studies have used pH monitoring to diagnose gastroesophageal reflux, with high sensitivity and specificity 5.
- A study published in 1994 found that rapid intragastric bolus infusion led to a reduction in lower esophageal sphincter (LES) pressure and free gastroesophageal reflux, while slow, continuous gastrostomy feedings did not alter LES pressure or show free gastroesophageal reflux by scintigraphy 6.
Detection of Aspiration Risk
To detect aspiration risk, scintigraphy can be used to evaluate reflux at both sites in patients at high risk of laryngopharyngeal reflux and lung aspiration 4.
- A study published in 1998 found that one patient had aspiration into the lungs, and that scintigraphy is useful in assessing GER in PEG-fed patients, especially in those with neurological dysphagia 3.
- A study published in 2020 found that none of the asymptomatic volunteers showed supine reflux or lung aspiration, but that a significant proportion of asymptomatic volunteers demonstrate upright reflux only 4.